Treatment planning consists of developing a logical sequence of treatment designed to restore the patients dentition to good health, optimal function , and optimal appearance. The plan should be presented in writing and discussed in detail with the patient. Good communication with the patient is critical as the plan is formulated. Most dental problems can be solved in a number of different ways; the patients preferences and are paramount in establishing an appropriate treatment plan. In appropriate proper planning; the patient is informed about the current conditions and problems, the extent of dental treatment that is proposed, the time and cost of treatment, and the level of home care and professional follow-up necessary for success. Also, before any irreversible procedures are initiated, the patient should understand that some of the planned procedures may need to becomes available
IDENTIFICATION OF PATIENT NEEDS
Successful treatment planning is based on proper identification of the patients needs. If the dentist attempts to make the patient conform to the (ideal) treatment plan rather that make the treatment plan conform to the patients needs, success is unlikely. In many cases, several plans are presented and discussed, each with advantages and disadvantages. Indeed ,failing to explain and present available options may be considered legally negligent
Treatment is necessary to accomplish one or several of preventing future disease, restoring function, and improving appearance
Correction of Existing Disease
Existing disease is revealed during the clinical examination. Active disease can usually be halted by identification and reduction of the initiating factors, identification and improvement of the resistive factors,or both. For example, oral hygiene instruction helps reduce the amount of residual plaque, an initiating factor, and thus helps reduce the likelihood of further dental caries. Such instruction also helps improve gingival heaith, and the resulting healthy tissue is moore resistant to disease. In such patients with extensive caries, additional preventie measures are necessary (e.g., mouth rinses, high-fluoride toothpastes, dietary analysis). Restorative treatment replaces damaged or missing tooth structure, but additional treatment is crucial to control the underlying causes.
Prevention of Future Disease
The likelihood of future disease can be predicted from the patients disease experience and from the prevalence of the disease in the general population. Treatment should be proposed if future disease seems likely in the absence of such intervention.
One of the first phases of treatment is to stabilize active disease, which often includes replacement of defective restorations and treatment of carious lesions. If a patient presents initially with poor oral hygiene, the dentist should monitor if improvement in plaque control results during the stabilization phase. If such does not occur, renewed emphasis on proper oral hygiene measures is indicated. Subsequently identified limitations in the patients oral hygiene may justifiably affect the final treatment plan.
Restoration of Function
Although objective measurement can be difficult, the level of function is assessed during the examination. Treatment may be proposed to correct impaired function (e.g., mastication or speech). Prerequisite treatment may include mandibular repositioning through occlusal reshaping before fixed prosthodontic treatment and orthodontically repositioning teeth in more favorable locations before missing teeth are replaced.
Improvement of Appearance
Patients often seek dental treatment because they are dissatisfied with their appearance. However, it is difficult to assess dental esthetics objectively. The dentist should develop expertise in this area and should be prepared to appraise the appearance of the patients dentition and listen carefully to the patients views. If the existing appearance is far outside socially accepted values, the feasibility (and liminations) of corrective procedures should be brought to the patients attention. Long-term dental health should not be compromised by unwise attempts to improve appearance.
Patients should always be made aware of the possible adverse consequences of treatment.
AVAILABLE MATERIALS AND TECHNIQUES
All existing restorative materials and techniques have limitations, and none exactly match the properties of natural tooth structure. Clinicians must understand these limitations before they can select the appropriate procedure. This helps prevent an experimental approach to treatment
Plastic Materials
Plastic materials (e.g., silver amalgamn or composite resin) are the most commonly uesd dental restoratives. They allow simple and conservative restoration of damaged teeth. However, their mechanical properties are inferior to those of cast metal or metal-ceramic restorations. Their longevity depends on the strengh and integrity of the remaining tooth structure. When the tooth structure needs reinforcement, a cast metal restoration should be fabricated, often with amalgam or composite resin as the foundation or core
Larger amalgam restoration (fig A) are shaped or carved directly in the mouth. Because of the great degree of difficulty with this direct approach, defective contours and poor occlusion aften result. The indirect procedure, used in making crows (see fig. B and C) facilitates the fabrication of more
accuretely shaped restorations.
A
B
C
Cast Metal
Cast metal crowns (see fig., B) are fabricated in the dental laboratory and are cemented with a luting agent.
They fit over a prepared tooth, somewhat like a thimble's fitting on a finger. To minimize exposure of the luting agent to oral fluids, a long-lasting crown must fit the tooth well. Precise technique enables the routine fabrication of metal crowns with excellent margine fit and precisely shaped axial and occlusal surfaces. Replication of optimal anatomic form in crows helps maintain periodontal health and good occlusal function. The internal dimensions of a crown must allow it to seat without binding against the vertical preparation walls while remaining stable and not becoming displaced during function. Thus crowns must be fabricated to precise tolerances.
Intracoronal Restorations
An interacoronal cast metal restoration, or inlay, relies on the strength of the remaining tooth structure for support and retention, just as a plastic restoration dose. However, greater tooth bulk is needed to resist any wedging effect on the preparation walls. Therefore, this restoration is contraindicated in a significantly weakened tooth. When fabricated correctly, intracoronal inlays are extremely durable because of the strength and corrosion resistance of the gold casting alloy; however, in a tooth with a minimal proximal carious lesion, an inlay usually necessitates greater removal of tooth structure than dose an amalgam preparation
Extracoronal Restorations
An extracoronal restoration cast metal restoration, or crown, encircles all or part of the remaining tooth structure and the occlusal surface. Crowns strengthen and protect teeth weakened by caries or trauma. To provide the necessary bulk of material for strenght, considerably more tooth structure must be removed than for an intracoronal restoration. The margins of an extracoronal restoration often must be near or below the crest of the free gingiva, which can make maintenance of tissue health difficult. Tooth preparation for an extracoronal restoration may be combined with intracoronal features (e.g., grooves and pinholes) to obtain retention mechanical advantage
Metal-Ceramic Material
Metal-ceramic crowns consist of a tooth-colored layer of porcelain bonded to a cast metal substructure. They are used when a complete crown is needed to restore appearance and function. Tooth structure must be reduced sufficiently to provide space for the bulk of porcelain needed for a natural appearance. Thus the preparation design for a metal-ceramic crown is among the least conservative, although tooth structure can be conserved if only the most visible part of the restoration is veneered
The labial margins of a metal-ceramic restoration are often discernible and may detract from its appearance. They can be hidden by subgingival placement, although they then have the potential for increasing gingival inflammation; this should be avoided when possible
Appearance can be improved by omitting the metal shoulder and making the labial margin in porcelain
Fiber-Reinforced Resin
Advances in composite resin technology, especially the introduction of glass and polythylene fibers, have prompted the use of indirect composite resin restorations for inlays, crowns, and FDPs. Excellet marginal adaptation and esthetic results are achievable, but they do not withstand functional loads well over time. Therefore, they are very useful as long-term interim restorations
Complete Ceramic
Crowns, inlays, and laminate veneers made entirely of dental porcelain are among the most esthetically pleasing of all fixed restorations. Drawbacks include a comparative lack of strength and-depending on the fabrication method used-the difficulty in achieving an acceptable internal and marginal fit. Some all-ceramic restorations are fabricated in the dental office, whereas others must be fabricated in the dental laboratory. In general, the internal fit of some of the laboratory fibricated restorations is superior to that of those fabricated by milling in the dental office. The advantage of the latter is that the esthetic restoration can be placed in a single appointment without the need for an interim restoration. The current focus in improving the strength of esthetic restorations is on either veneering a high-strength alumina, zirconia, spinel, or lithium disilicate core with a more translucent porcelain or using a leucite-reinforced translucent material. Monolithic esthetic restorations are among the strongest ceramic restorations, and colored monolithic zirconia crowns have very acceptable esthetics for posterior teeth. Complete ceramic restorations are fabricated by an indirect technique, and etchable ceramic crowns are generally retained with composite resin. The acid etching of the internal crown surface is used to provide retention "keys."
Fixed Dental Prostheses
A FDP is often indicated when one or more teeth must be removed or are missing. Such teeth are replaced by pontics that arebdesigned to fulfill the functional and often the esthetic requirements of the missing teeth. Pontics are attached with connectors to the FDP retainers, which are the restorations on prepared abutment teeth.
All the components of an FDP are fabricated and assembled in the laboratory before cementation in the mouth. This requires precise alignment of tooth preparations. Because unseating forces on individual retainers can be considerable, retentive restorations are essential.
FDPs have been demonstrated to have exceptional long-term success, which is ensured by controlling the magnitude and direction of loading and by making sure the patient practices appropriate oral hygiene measures.
Implant-Supported Prostheses
Single or multiple missing teeth can be replaced with an implant-supported prostheses. 
For the successful "osseointegrated" technique, the bone is atraumatically drilled to receive precisely fitting titanium cylinders. These are either left in place without loading for several months until they are osseointegrated or restored immediately with an interim restoration. Then function and esthetics are restored with a prosthesis.
Partial Removable Dental Prosthesis
A partial removable dental prothesis (RDP) is designed to replace missing teeth and their supporting structures. Forces applied to a well-designed partial RDP are distributed to the remaining teeth and the residual alveolar ridges. These forces are most accurately controlled if the abutment teeth can be reshaped with fixed cast restorations that have carefully contoured guide planes and rest seats. Specific design requirements of the partial RDP can affect tooth prepaaration design for such survey crowns.
Complete Dentures
Common difficulties encountered with complete dentures relate to the lack of denture stability and gradual loss of supporting bone over time. Denture stability is enhanced if the denture has a carefully designed occlusion. Problems with maxillary denture stability can be especially severe when the mandibular incisors are the only teeth retained, with ensuing damage to the opposing premaxilla, although any treatment plan that involves a complete denture opposing fixed restorations requires careful planning of the occlusion. For selected patients, providing an overdenture that rests on endodontically treated roots may help preserve the residual ridge and enhance the stability of the complete denture.
TREATMENT FOR TOOTH LOSS
A treatment plan involving fixed prostheses often includes the replacement of missing teeth. In most cases, the loss of teeth is a result of dental caries or periodontal disease. In rare cases, they may be congenitally absent or lost as a result of trauma or neoplastic disease.
Decision to Remove a Tooth
The decision to remove a tooth is made after the advantages and disadvantages of its retention are weighed. Sometimes it is possible to retain a tooth with an apparently hopeless prognosis through highly specialized and complex techniques. In those circumstances, the patient must thoroughly understand the risks and benefits of the treatment decision. In other cases, removing the tooth is the treatment of choice.
decision if and how a missing tooth will be replaced is best made at the time its removal is recommended, rather than months or years after the fact.
Consequences of Removal without Replacement
The decision to replace or not replace missing teeth requires a careful analysis of the costs and benefits of the action. As a result of the loss of posterior support in association with posterior tooth loss, excessive forces may be exerted on the remaining dentition, causing damage and poor function. However, studies have demonstrated that adequate function is possible with reduced posterior occlusion, although replacing a missing second molar with an implant-supported crown has been shown to improve both objective masticatory ability and subjective satisfaction. Not replacing a tooth may lead to a situation in which normal tooth alignment cannot be maintained. The balance of forces previously exerted on that tooth by the adjacent and opposing teeth and supporting tissues and by the soft tissues of the cheeks, lips, and tongueis upset. Consequences may be supraocclusion of the opposing tooth or teeth, tipping of the adjacent teeth into the new edentulous space, and loss of proximal contact of the tooth that tips away from the neighboring tooth. In turn, these consequences may result in disturbances in the health of the supporting structures and the occlusion. However, the teeth adjacent to an edentulous space have not been shown to be at greater risk of damage, and the rate of positional change of teeth adjacent to an edentulous space is usually slow.
However, if significant movement of adjacent teeth has occurred, simple replacement of the missing tooth at this late stage may prevent further disruption =, although it may be insufficient to allow the dentition to return to full health. Extended treatment plans, including orthodontic repositioning and additional cast restorations (to correct the disturbed occlusal plane), may be needed to compensate for the lack of timely treatment at the time of tooth removal.
SELECTION OF ABUTMENT TEETH
Whenever possible, FDPs should be designed as simply as possible, with a single well-anchored retainer fixed rigidly at each end of the pontic. The use of multiple splinted abutment teeth, nonrigid connectors, or intermediate abutments makes the procedure much more difficult, and in many cases, the result compromises the long-term prognosis.
Replacement of a Single Missing Tooth
Unless bone support has been weakened by advanced periodontal disease, a single missing tooth canual caries are removed almost always be replaced by a three-unit FDP that includes one mesial and one distal abutment tooth. An exception is when the FDP is replacing a maxillary or mandibular canine tooth. Under these circumstances, the small lateral incisor needs to be splinted to the central incisor to prevent lateral drift of the FDP. This use of two abutment teeth on the anterior aspect is referred to as double-abutting.
Cantilever Fixed Dental Prostheses
FDPs in which only one side of the pontic is attached to a retainer are referred to as cantilevered. An example would be a lateral incisor pontic attached only to an extracoronal metal-ceramic retainer on a canine tooth. Cantilevered FDPs remain popular because some of the difficulties encountered in making a three-unit FDP are lessened. Also, many clinicians are reluctant to prepare an intact central incisor, preferring instead to use a cantilever.
However, the long-term prognosis of the single-abutment cantilever is poor. Forces are best tolerated by the periodontal supporting structures when directed along the long axes of the teeth. This is the case when a simple three-unit FDP is used. A cantilever induces lateral forces on the supporting tissues, which may be harmful and lead to tipping, rotation, or drifting of the abutment.
Evaluation of Abutment Teeth
The dentist can save considerable time and expense, and can reinforce a patient's confidence, by thoroughly investigating each abutment tooth before proceeding with tooth preparation. Radiographs are made, and the dentist assesses pulpal health by evaluating the response to thermal or electrical stimulation, or both. Existing restorations, cavity liners, and residual caries are removed (preferably under a rubber dam), and a careful check is made for possible pulpal exposure. Teeth in which pulpal health is doubtful should be treated endodontically before fixed prosthodontic treatment is initiated. Although a direct pulp cap may be an acceptable risk under a simple amalgam or composite resin, conventional endodontic treatment is normally preferred when crowns are planned. Fixed prosthodontic treatment is time consuming and costly; when endodontic treatment is needed after a complex prosthesis has been fabricated, access must be established through the occlusal surface of the newly fabricated prosthesis, which jeopardizes its long-term prognosis and the overall success of treatment.
Endodontically Treated Abutments
If a tooth is properly treated endodontically, it can serve well as an abutment with a post and core foundation for retention and strength. Failures occur, however, particularly on teeth with short roots or little remaining coronal tooth structure. Care is needed to obtain maximum retention for the post and core. Sometimes it is better to remove a badly damaged tooth than to attempt endodontic treatment.
The type of restoration that is anticipated after endodontic treatment can help the dentist make the best decision. For instance, a maxillary premolar that requires a crown is typically restored with either an all-ceramic or metal-ceramic crown; if endodontic treatmnt is performed, a patient presenting with a maxillary buccal cusp fracture has a better prognosis than dose a patient presenting with a lingual cusp fracture. The esthetic crown requires a wide buccal shoulder preparation, which will significantly weaken the remaining buccal cusp, whereas the remaining lingual cusp can be prepared more conservatively, with retention of additional tooth structure and, consequently, a better prognosis.
Unrestored Abutments
An unrestored, caries-free tooth is an ideal abutment. It can be prepared conservatively for a strong retentive restoration with optimum esthetics. The retainer margin can be placed without the modifications often needed to accommodate existing restorations or caries. In an adult patient, an unrestored tooth can be safely prepared without jeoparding the pulp as long as preparation design and technique are wisely chosen. Some patients are reluctant to have a perfectly sound tooth cut down to support an FDP. In these cases, the overall dental health of the patient, rather than the condition of each individual tooth, should be emphasized.
Mesially Tilted Second Molar
Loss of a permanent mandibular first molar to caries early in life is still relatively common. If the resulting space is ignored, the second molar may drift mesially, especially with eruption of the third molar. It then becomes difficult or even impossible to make a satisfactory FDP because the positional relationship no longer allows for parallel paths of placement without interference from the adjacent teeth.
In such circumstances, an FDP is sometimes made with modified preparation designs or with a nonrigid connector; as an alternative, a straightforward solution may be considered: uprighting the tilted abutment orthodontically with a simple fixed appliance. However, the problem can be avoided altogether if a space-maintaining appliance is fabricated when the first molar is removed. This device may be as simple as a square section of orthodontic wire bent to follow the edentulous ridge and anchored with small restorations in the adjacent teeth.
Replacement of Several Missing Teeth
Fixed prosthodontic treatment becomes more difficult when several teeth must be replaced. Problems are encountered in restoring a single long, uninterrupted edentulos area or multiple edentulous areas with intermediate abutment teeth, especially when anterior and posterior teeth are to be replaced with a single FDP. Underestimation of the problems involved in extensive prosthodontic treatment can lead to failure. One key to ensuring a successful result is to plan the prostheses by diagnostically waxing the intended restorations on articulated diagnostic casts. This is essential for complex fixed prosthodontic treatments, particularly when an irregular occlusal plane is to be corrected, the occlusal vertical dimension is to be altered, an implant-supported prosthesis is recommended, or a combination of FDPs and partial RDPs is to be used. The precise end point of such complicated treatments can be far from evident, even to an experienced prosthodontist.
Overloading of Abutment Teeth
The ability of the abutment teeth to accept applied forces without drifting or becoming mobile must be estimated and has a direct influence on the prosthodontic treatment plan. These forces can be particulary severe during parafunctional grinding and clenching, and the need to eliminate them becomes obvious during the restoration of such damaged dentition. Although it is hoped that a well-reconstructed occlusion will reduce the duration and strength of any parafunctional activity, there is little scientific evidence to support this. It is unwise to initiate treatment on the assumption that new restorations will reduce parafunctional activity, unless this has been demonstrated with occlusal device treatment over a significant period.
Direction of Forces. whereas the magnitude of any applied force is difficult to regulate, a well-fabricated FDP can distribute these forces in the most favorable way: namely, directing them along the long axes of the abutment teeth. Potentially damaging lateral forces can be confined to the anterior teeth, where their effect is reduced by the greater distance from the fulcrum in the temporomandibular joints.
Root Surface Area. The root surface area of potential abutment teeth must be evaluated when fixed prosthodontic treatment is planned. Ante suggested in 1926 that it was unwise to provide an FDP when the root surface area of the abutments was less than the root surface area of the teeth being replaced; this suggestion has been adopted and reinforced by other authors as Ant's law.
As an example of Ante's law, consider the patient who has lost a first molar and a second premolar. In this situation, a four-unit FDP is an acceptable risk, as long as there has been no bone loss from periodontal disease, because the second molar and first premolar abutments have root surface areas approximately equal to those of the missing teeth. If the first molar and both premolars are missing, however, an FDP is not considered a good risk because the total root surface area of the teeth being replaced is greater than that of the potetial abutments.
Nyman and Ericsson, however, cast doubt on the validity of Ante's law by demonstrating that teeth with considerably reduced bone support can be successfully uesd as FDP abutments. In the majority of the treatments that they discussed, the abutment root surface area was less than half that of the replaced teeth, and there was no loss of attachment after 8 to 11 years. Nyman and Ericsson attributed this sussess to meticulous root planing during the active phase of treatment, proper plaque control during the observed period, and meticulous occlusal design of the prostheses. Other authors have confirmed that abutment teeth with limited periodontal bone can successfully support FDPs.
Root Shape and Angulation
When periodontal support is compromised, the root shape and angulation must be considered. A molar with divergent roots provides better support than dose a molar with conical roots and little or no interradicular bone. A single-rooted tooth with an elliptic cross section offers better support than dose a tooth with similar root surface area but with a circular cross section. Similarly, a well-aligned tooth provides better support than a tilted one.
Poor alignment can be improved with orthodontic uprighting. 
Periodontal Disease. After horizontal bone loss from periodontal disease, the periodontal ligament-supported root surface area can be dramatically reduced. Because of the conical shape of most roots, when one third of the root length has been exposed, half the supporting area is lost. In addition, the forces applied to the supportion bone are magnified because of the greater leverage associated with the lengthened clinical crown. Thus, potential abutment teeth need very careful assessment when significant bone loss has occurred.
In general, successful FDPs can be fabricated on teeth with severely reduced periodontal support if the periodontal tissues have been returned to excellent health and long-term maintenance has been ensured.
When extensive prosthetic rehabilitation is attempted without complete control over the health of the eriodontal tissues, the result can be disastrous.cing
Healthy periodontal tissues are a prerequisite for all fixed restorations. If the abutment teeth have normal bone support, an occasional lapse in plaque removal by the patient is unlikely to affect the long-term prognosis. However, when teeth with severe bone loss resulting from periodontal disease are uesd as abutments, there is very little tolerance. It then becomes imperative that excellent plaque-removal technique be implemented and maintained at all times.
Replacing three posterior teeth with an FDP rarely has a favorable prognosis, especially in the mandibular arch. Under such circumstances, an implant-supported prosthesis or a partial RDP often has a better long-term prognosis.
If, nevertheless, a long -span FDP is fabricated, pontics and connectors cross sectionally should be made as bulky as possible o ensure optimum rigidity without jeopardizing gingival health. In addition, the prosthesis should be made of a material that has high strength and rigidity.
Replacing Multiple Anterior Teeth
When anterior teeth are replaced, special considerations include problems with appearance and the need to resist tipping forces not directed parallel to the long axes of the teeth.
The four mandibular incisors can usually be replaced by a simple FDP with retainers on each canine tooth. It is not usually necessary to include the first premolars. If a lone incisor remains, it should be removed because its retention unnecessarily comlicates the FDP design and fabrication and can jeopardize the long-term prognosis. Mandibular incisors, because of their small size, are poor abutment teeth. It is particularly important not to have overcontoured restorations on these teeth because plaque control may become nearly impossible. Thus, the clinician may have to make a choice among (1) compromised esthetics from too thin a ceramic veneer, (2) pulpal exposure during tooth preparation, and (3) selective tooth removal.
Restoration of appearance and providing support after the loss of several maxillary incisors presents a much greater challenge. Because of the curvature of the dental arch, forces directed against a maxillary incisor pontic tend to tip the abutment teeth outward. Unlike the mandibular incisors, the maxillary incisors are not positioned in a straight line (particlarly in patients with narrow or pointed dental arches). These tipping forces must be resisted by means of additional abutment teeth at each end of a long-span anterior FDP. Thus in general, when the four maxillary incisors are replaced, the canine teeth and first premolars should be used as abutment teeth. There may be considerable difficulty in achieving a good appearance when several maxillary incisors are replaced with an FDP. Obtaining optimal tooth contours and position for appearance and phonetics can be a challenge. A diagnostic waxing procedure is extremely helpful to evaluate specific esthetic problems. As treatment progresses, an interim restoration is provided. This is uesd to test appearance, lip support, and phonetics. It may also be readily shaped and modified until the patient is satisfied with its appearance, after which the final restoration can be made to copy it, thereby avoiding and embarrassing misunderstandings when the finished FDP is delivered.
If anterior bone loss has been severe, as can happen when teeth are lost as a result of trauma or periodontal disease, there may be a ridge defect. In an affected patient, a partial RDP should be considered, especially when the patient has a high smile line, because an FDP generally replaces only the missing tooth structure, not the supporting tissues. Again, an interim restoration may help the patient and dentist jointly determine the most appropriate treatment. A surgical ridge augmentation procedure may also be an option, although the surgical result can be somewhat unpredictable.
Indication for Partial Removable Dental Prostheses
Whenever possible, it is preferable to restore edentulous spaces with FDPs rather than partial RDPs. A well-fabricated FDP improves health and has better function than dose a partial RDP and is preferred by most patients. Under the following circumstances, however, a partial RDP is indicated:
- Where vertical support from the edentulous ridge is needed; for example, in the absence of a distal abutment tooth.
- Where resistance to lateral movement is needed from contralateral teeth and soft tissues; for example, to ensure stability with a long edentulous space.
- When there is considerable bone loss in the visible anterior region and an FDP would have an unacceptable appearance.
TREATMENT SEQUENCE
When a patient's needs have been identified and the appropriate corrective measures have been determined, a logical sequence of steps must be decided on, including the treatment of symptoms, stabilization of deteriorating conditions, definitive therapy, and a program of follow-up care. The importance of proper sequencing is emphasized because mistakes can lead to compromised effort or unnecessary and expensive remakes.
Treatment of Symptoms
The relief of discomfort accompanying an acute condition is a priority in planning treatment. Discomfort can result from one or more of the following: a fractured tooth or teeth, acute pulpitis, acute exacerbation of chronic pulpitis, a dental abscess, acute pericoronitis or gingivitis, and myofascial pain dysfunction. The clinician needs only sufficient diagnostic information to ascertion the nature of a particular condition and to form a diagnosis; treatment is instituted without delay. A full examination is neither desirable nor generally possible until the symptoms of such an acute condition have been addressed.
Urgent Treatment of Nonacute Problems
Fortunately, most potential candidates for fixed prosthodontic treatment do not seek treatment for acute conditions; however, they may have a specific problem that warrants immediate attention, such as a lost anterior crown, a cracked or broken porcelaoin veneer, or a fractured partial RDP.
Stabilization of Deteriorating Conditions
The second treatment phase involves stabilizing deteriorating conditions such as dental caries or periodontal disease by removing the etiologic factors, increasing the patient's resistance, or doing both.
Dental caries
Treatment of carious lesions is approached in a conventional manner, and the teeth are restored with properly contoured plastic materials. These may serve as a foundation for FDPs during a subsequent phase of treatment. However, definitive crowns are best avoided in a patient with active caries because the results of such extensive treatment will be jeopardized by disease recurrence. This risk can be addressed through a combination of dietary advice, oral hygiene measures, and fluoride treatment and regular follow-up appointments to monitor the patient's progress.
Periodontal Disease
Chronic periodontitis with continuing irreversible bone loss should be treated as early as possible by effective daily plaque control. The proper removal of plaque is possible only if the teeth are smooth and their contours allow unimpeded access to the gingival sulci. Therefore, the following procedures are essential:
- Replacement of defective restorations
- Removal of carious lesions
- Recontouring of overcontoured crowns (especially near furcation areas)
- Proper oral hygiene instruction and adequate implementation at home
Definitive Therapy
When the stabilization phase has been completed, successful elective long-term treatment aimed at promoting dental health, restoring function, and improving appearance can begin. On occasion, this takes considerable time. Several therapeutic proposals may be applicable to a single patient and may range in complexity from minimum restorative treatment with regular maintenance to full-mouth prosthodontic rehabilitation preceded by orthognathic surgery and orthodontic treatment. The advantages and disadvantages of all presented options should be thoroughly explained to the patient. Diagnostic casts and waxings are highly effective communication tools. When the dentist develops a definitive treatment plan, he or she should strive to reduce the risk of having to repeat earlier treatment if problems later occur. Usually oral surgical procedures are scheduled first, followed by periodontics, endodontics, orthodontics, fixed prosthodontics, and finally, removable prosthodontics.
Oral surgery
The treatment plan should allow time for healing and ridge remodeling. Therefore, teeth with a hopeless prognosis, unerupted teeth, and residual roots and root tips should be removed early. Similarly, all preprosthetic surgical procedures (e.g., ridge contouring) should be under-taken during the early phase of treatment.
Periodontics
Most periodontal procedurs should (or will) have been accomplised as part of the stabilization phase of treatment. Any surgery, pocket elimination, mucogingival procedure, guided tissue regeneration, or root resection is performed at this time.
Endodontics
Some endodontic treatment may have been accomplished as part of the relief of discomfort and stabilization of conditions. Elective endodontic treatment may be needed to provide adequate space for a cast restoration or to provide retention for a badly damaged or worn tooth.
If a tooth with doubtful pulpal health is to be used as an abutment for an FDP, it should be endodontically treated prophylactically, despite the consideration that periodic recall might have been a.
more appropriate treatment if a single restoration were planned.
Orthodontics
Minor orthodontic tooth movement is a commen adjunct to fixed prosthodontic treatment, and the benefit of moving teeth into their optimal locations to accommodate subsequent prosthodontic treatment cannot be overemphasized Too often an effort is made in the dental laboratory to "correct" anatomic form while the supporting abutment is malpositioned. such efforts invariably affect the prognosis adversely. Teeth can be uprighted, rotated, moved laterally, intruded, or extruded to improve their relationship before fixed prosthodontic treatment is initiated. Orthodontic treatment should always be considered when a treatment plan is proposed, especially if tooth loss has been neglected and drifting has occurred.
Fixed Prosthodontics
Fixed prosthodontic treatment is not initiated until the preparatory procedures have been completed. This permits modification of the original plan if unforeseen difficulties surface during treatment. For example, a tooth scheduled for endodontic treatment might prove to be untreatable, resulting in its loss, and necessitating considerable modification of the initial fixed prosthodontic treatment plan.
Occlusal Reshaping. Occlusal reshaping is often necessary before fixed prosthodontic treatment is started. Its rationale is twofold: Either occlusal reshaping may help reduce neuromuscular pathology, or occlusal reshaping assists in achieving orthopedic stability prerequisite to comprehensive fixed prosthodontic rehabilitation. When extensive fixed prosthodontic treatment is to be provided, an accurate and well-tolerated occlusal relationship may be obtainable only if a slide between maximal intercuspation and centric relation is eliminated first. When less extensive treatment is planned, it may be acceptable to modify the FDP to conform to the existing occlusion, provided the patient is functioning satisfactorily. However, any supraeruption or drifting should be corrected rather than be allowed to compromise the patient's occlusal scheme.
Anterior Restorations. If both anterior and posterior teeth are to be restored, the anterior teeth usually restored first because they influence the border movements of the mandible and thus affect the shape of the occlusal surface of the posterior teeth. If the posterior teeth are restored first, a subsequent change in the lingual contour of the anterior teeth could necessitate considerable adjustment of the posterior restorations.
Posterir Restorations. Restoring opposing posterior segments at the same time is often advantageous. This allows the development of an efficient occlusal scheme through the application of an additive wax technique. If at all feasile, treatment of one side of the mouth should be completed before the other side is treated; restoring all four posterior segments at the same time can readily lead to considerably more complications for the patient and dentist, including fracture or breaking of interim restorations, discomfort with bilateral local anathesia, and difficulties in confirming the accuracy of jaw relationship recordings.
Complex Prosthodontics. Carefully planned treatment sequencing is critically important in the planning of complex prosthodontic treatments involving alteration of the vertical dimension or a combination of FDPs and partial RDPs. One recommended approach is the use of cross-mounted diagnostic casts. Tow sets of diagnostic casts are accurately mounted so they can be precisely interchanged on the articulator. One set is prepared and waxed to the intended end point of treatment, with denture teeth inserted where partial RDPs are to be used. The waxing is carefully evaluated on the articulator in relation to occlusion and appearance. When anterior teeth are to be replaced, they can be assessed for appearance and phonetics directly in the mouth if they are mounted on a removable record base. Definitive tooth preparation starts in one arch only, so that the occlusal surfaces of the opposing arch are preserved to act as an essential reference for mounting the definitive cast. The definitive restoration are waxed against the diagnostically waxed cast, which establishes optimal occlusion. When one arch has been completed, the opposing cast can be restored and the predicted result thus achieved.
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